Form 3 Detailed Driver Activity Data Collection Form

FMCSA Under 21 Military Commercial Drivers Pilot Program

Motor Carrier Data Collection Form

OMB Control Number: XXXX-XXXX Expiration Date: MM/DD/YYYY

Privacy Statement

• Authority: 49 CFR 381.400; Pub. L. 114-94, Dec. 4, 2015, 49 USC 31315 Section 5404

• Purpose: FMCSA will be collecting this data for use in the research effort title “Pilot Program to Allow 18- to 21-Year-Old Persons with Military Driving Experience to Operate Commercial Motor Vehicles (CMVs) in Interstate Commerce”. Additionally, this data may be used for future undetermined research efforts, but cannot be used for enforcement purposes.

• Routine Uses: In addition to those disclosures permitted under 5 USC 552a(b) of the Privacy Act of 1974, additional disclosures may be made in accordance with the U.S. Department of Transportation (DOT) Prefatory Statement of General Routine Uses published in the Federal Register on December 29, 2010 (75 FR 82132), under ‘‘Prefatory Statement of General Routine Uses’’ (available at http://www.dot.gov/privacy/privacyactnotices).

• Disclosure: The disclosure of this data is voluntary, however, failure to provide the requested information may result in dismissal from participating in the pilot program. For drivers granted privilege to operate under an exemption through this program, dismissal from the pilot program will result in the denial to continue operating under that exemption.

This form is to be used to record driver activity and safety outcome data for the reporting period.
MOTOR CARRIER INFORMATION
MOTOR CARRIER NAME	U.S. DEPARTMENT OF TRANSPORTATION NUMBER	REPORTING START DATE (mm/dd/yyyy)	REPORTING END DATE (mm/dd/yyyy)
DRIVER INFORMATION
DRIVER NAME (Last, First, Middle)	STATE/DRIVER LICENSE NUMBER	MILITARY DRIVER LICENSE NUMBER (if Covered Driver)
Did a Disqualifying Event occur during this reporting period?  YES  NO	If yes, specify the Disqualifying Event(s).

DRIVER TRIP-LEVEL DATA FOR THE REPORTING PERIOD (enter this information for all trips that occurred during the reporting period for the driver listed above)

TRIP NUMBER

START LOCATION (City, State)

END LOCATION (City, State)

START DATE (mm/dd/yyyy)

END DATE (mm/dd/yyyy)

START TIME (00:00:00 UTC)

END TIME (00:00:00 UTC)

MILES TRAVELED

HOURS DRIVEN

TRUCK TYPE

HOURS SINCE LAST BREAK

ALL CRASHES

DOT REPORTABLE CRASHES

ROADSIDE INSPECTION VIOLATIONS (CSA POINTS ACCRUED)

NO. OF INSPECTIONS

MOVING VIOLATIONS

MOTORIST INCIDENT REPORTS

NEAR CRASHES (as recorded by the OBMS if installed)

CRITICAL EVENTS (as recorded by the OBMS if installed)

1

2

3

4

5

6

7

8

9

10

11

12

OTHER ATTACHMENTS

If the driver was involved in any crashes during the reporting period, attach the Motor Carrier’s Post-Crash Investigation Summary and the Law Enforcement Crash Report of the investigating law enforcement agency. Attach the On-Board Monitoring System (OBMS) Logs for the drivers, if installed, on the vehicles.

Public Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is XXXX-XXXX. Public reporting for this collection of information is estimated to be approximately XX minutes per response, including the time for reviewing instructions and completing and reviewing the collection of information. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.